Notice2024-26066
TRICARE: Notice of TRICARE Plan Program Changes for Calendar Year 2025
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
November 8, 2024
Issuing agencies
Defense Department
Abstract
This notice provides information regarding TRICARE Plan Program Changes for Calendar Year (CY) 2025.
Full Text
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<title>Federal Register, Volume 89 Issue 217 (Friday, November 8, 2024)</title>
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[Federal Register Volume 89, Number 217 (Friday, November 8, 2024)]
[Notices]
[Pages 88742-88744]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2024-26066]
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DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE: Notice of TRICARE Plan Program Changes for Calendar Year
2025
AGENCY: Office of the Secretary of Defense, Department of Defense
(DoD).
ACTION: Notice; TRICARE Plan Program Changes for Calendar Year 2025.
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SUMMARY: This notice provides information regarding TRICARE Plan
Program Changes for Calendar Year (CY) 2025.
DATES: TRICARE Health Plan information in this notice is valid for
services during CY 2025 (January 1, 2025-December 31, 2025).
ADDRESSES: Defense Health Agency, TRICARE Health Plan Division, 7700
Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.
FOR FURTHER INFORMATION CONTACT: Ms. Debra Fisher, phone: (703) 275-
6224.
SUPPLEMENTARY INFORMATION: A final rule published in the Federal
Register (FR) on February 15, 2019, (84 FR 4326-4333) established the
requirement for the Director, Defense Health Agency (DHA), to provide
public notice to Military Health System (MHS) beneficiaries each
calendar year in connection with the annual open season enrollment
period with a summary of changes to the TRICARE program. The following
changes or improvements to the TRICARE program benefits apply for CY
2025.
Announcement of Open Season
Open Season is an annual period when beneficiaries can enroll in or
make changes to their healthcare, dental, and vision coverage for the
next calendar year.
During the TRICARE Open Season that runs from November 11, 2024,
through December 10, 2024, qualified MHS beneficiaries may enroll in or
change their TRICARE Prime or TRICARE Select plan.
During the Federal Employee Dental and Vision Insurance Program
(FEDVIP) Open Season that runs from November 11, 2024, through December
9, 2024, qualified MHS beneficiaries, including TRICARE for Life
beneficiaries, may enroll in or make changes to their dental and vision
plans. FEDVIP is operated by the U.S. Office of Personnel Management.
Any changes MHS beneficiaries make during Open Season will take
effect on January 1, 2025. If a beneficiary remains eligible and does
not make any changes during Open Season, then their coverage will stay
the same for 2025. TRICARE enrollees can ensure they receive important
health plan information by promptly listing any change in address and
other information in the Defense Enrollment Eligibility Reporting
System (DEERS). See the Qualifying Life Events (<a href="https://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLEhttps://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLE">https://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLEhttps://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLE</a>) guide for when to
update information in DEERS throughout the year.
Annual Announcements
The following TRICARE program features are subject to a year-to-
year determination and are announced each year prior to the annual
TRICARE Open Season.
Urgent Care Visits: There continues to be no limit on the number of
urgent care visits covered beneficiaries enrolled in TRICARE Prime can
receive without a referral for Plan Year 2025. Beneficiaries may
receive urgent care from TRICARE-authorized urgent care centers (UCC)
and convenience clinics (CC), either network or non-network, without a
referral. They may also receive urgent care from any TRICARE network
provider (i.e., family medicine; internal medicine-general practice;
pediatricians). In situations when a TRICARE Prime enrollee seeks care
from a non-network TRICARE authorized provider (outside of a TRICARE-
authorized UCC or CC), the usual TRICARE Prime Point of Service (POS)
deductible and cost-shares shall apply. Private Sector care for active
duty Service members is subject to different rules. Covered
beneficiaries who want assistance on decisions to seek urgent care in
the United States (U.S.), except those enrolled in the Uniformed
Services Family Health Plan (USFHP), may call the MHS Nurse Advice Line
[[Page 88743]]
(NAL) at 1-800-874-2273 for health care guidance from a specially
trained registered nurse. The NAL is available 24/7 to all non-USFHP
TRICARE beneficiaries. Beneficiaries who live overseas can call the NAL
for health care advice when traveling in the U.S. but must coordinate
care with their Overseas Regional Call Center. For additional
information, call the servicing TRICARE contractor or visit <a href="https://www.tricare.mil/ContactUs">https://www.tricare.mil/ContactUs</a> and click on ``MHS Nurse Advice Line.''
Prime Service Area Changes: Prime Service Areas (PSAs) are
geographic areas around military medical treatment facilities and Base
Realignment and Closure sites. PSAs support the medical readiness of
active duty members of the Uniformed Services by adding to the
capability and capacity of military hospitals and clinics. There are no
changes to the existing PSAs for calendar year (CY) 2025.
What's New
The following changes or improvements to the TRICARE program
benefits apply to CY 2025 (although some changes were implemented in
2024):
Managed Care Support Contractors
TRICARE Managed Care Support Contracts for East and West Regions
Change: Effective January 1, 2025, a set of new TRICARE Managed Care
Support contracts that facilitate health care in the private sector
will serve beneficiaries in the East and West regions. Under the new
contracts, beneficiaries residing in Arkansas, Illinois, Louisiana,
Oklahoma, Texas, and Wisconsin will shift from the East to the West
region.
Note: Beneficiaries residing in Arkansas, Illinois, Louisiana,
Oklahoma, Texas, and Wisconsin, and TRICARE Prime and Select
beneficiaries transitioning from HealthNet Federal Services to
TriWest must contact their regional contactor if they are paying
enrollment fees or premiums by recurring credit card and electronic
funds transfer (EFT) to provide their payment information to ensure
there is no break in TRICARE health care coverage.
Beneficiaries in the West Region will have a new contractor
administering their TRICARE benefit, TriWest Health Alliance.
Contractor contact information for West Region beneficiaries receiving
services on or after January 1, 2025, is provided here: TriWest
Healthcare Alliance, P.O. Box 43470, Phoenix, AZ 85080-3470, Phone: 1-
888-TRIWEST (874-9378); Fax: 1-866-566-9915, <a href="http://www.tricare.mil/West">www.tricare.mil/West</a>.
Beneficiaries in the East Region will continue to have their TRICARE
benefits administered by Humana Government Business.
The TRICARE East and West contracts include new requirements added
to allow enrolled beneficiaries to call their regional contractors to
get help with network appointments. This requirement is intended to
assist beneficiaries currently enrolled to the network who need support
for making appointments. Beneficiaries who frequently encounter
problems with network providers not accepting new patients can contact
the regional contractor for assistance.
Benefit Changes
Coverage of Hearing Aids for Child Dependents of Former Members of
the Uniformed Services: Hearing aids and hearing aid services and
supplies to address profound hearing loss may be covered for child
dependents of former members of the Uniformed Services who are enrolled
in TRICARE Prime, effective December 22, 2023. Hearing aid benefits are
available to dependents of a member of the Uniformed Services on active
duty, which includes all members covered under the Transitional
Assistance Management Program.
Automatic Blood Pressure Monitors: Automatic blood pressure
monitors may be covered under TRICARE's Durable Medical Equipment
policy, when prescribed for a beneficiary who is also receiving covered
Remote Physiologic Monitoring services, for medically necessary self-
measured blood pressure monitoring, effective June 29, 2023.
Lipectomy (Liposuction) for Treatment of Lipedema: Medically
necessary liposuction for the treatment of lipedema may be covered when
certain coverage criteria are met and with prior authorization,
effective May 28, 2021.
TRICARE Coverage for Over-The-Counter (OTC) Norgestrel: The TRICARE
pharmacy formulary for OTC drugs covers Norgestrel (Opill) tablet with
a doctor's prescription. TRICARE plan copayments or cost-shares may
apply. This addition to the TRICARE drug formulary does not change OTC
coverage of Levonorgestrel (Plan B One-Step Emergency Contraceptive)
for free without a doctor's prescription. Beneficiaries may see the
TRICARE drug formulary search tool for further information.
Demonstration Changes and Extensions
Childbirth and Breastfeeding Support Demonstration (CBSD)
Childbirth Support Services Adjustments: The CBSD will continue into
calendar year 2025 and is available to all beneficiaries except those
enrolled in USFHP, the Continued Health Care Benefit Program, and those
receiving TRICARE coverage under TRICARE for Life, with the following
adjustments.
First, starting January 1, 2025, all Certified Labor Doulas (CLDs)
performing services under the CBSD must have an agreement to
participate with TRICARE, which means the CLD must file claims and
accept TRICARE reimbursement as payment in full. Beneficiaries must
select a CLD who has agreed to participate (in-network or out-of-
network) to have TRICARE pay for services. No coverage will be provided
for services received from a CLD without a TRICARE participation
agreement. Beneficiaries who select a TRICARE-participating CLD will
have no out-of-pocket expenses (after the annual deductible has been
met). Second, the allowance for six untimed visits with a CLD either
before or after delivery are replaced by six hours of visits, which can
be used in 15-minute increments for visits of different lengths. Third,
TRICARE raised the reimbursement rates for CLDs. Fourth, the National
Black Doula Association has been added as an accepted certifying
organization for CLDs. Finally, TRICARE is waiving the certification
requirement for CLDs with active Medicaid participation in the state
where practicing. Phase 1 will end on January 1, 2025, and a new Phase
2 reimbursement for childbirth support services provided in the 50
United States and District of Columbia will be effective from January
1, 2025, through December 31, 2026. For overseas locations, the
effective date for Phase 2 reimbursement is also January 1, 2025,
through December 31, 2026.
CBSD Overseas: Starting January 1, 2025, beneficiaries enrolled to
the TRICARE Overseas Program (TOP) are eligible for demonstration
services (doula support and breastfeeding support by authorized
demonstration providers) when all demonstration requirements are met.
Unlike in the U.S., TOP beneficiaries must enroll in the CBSD with the
overseas contractor to be eligible. Beneficiaries can search provider
directories to locate CBSD providers near them in Germany, Japan,
Italy, South Korea, Puerto Rico, and the United Kingdom; in other
countries, the overseas contractor will work with the enrolled
beneficiary to find a qualified provider, if available.
Preventive Service Changes
Pre-Exposure Prophylaxis (PrEP) for, for the Prevention of HIV
Acquisition: Effective January 1, 2025, HIV pre-exposure prophylaxis
with effective antiretroviral therapy (i.e., Apretude), as
[[Page 88744]]
well as related office visits, for adolescents and adults at increased
risk of acquiring HIV, when provided to TRICARE Prime patients of by
network providers to TRICARE Select patients, will be considered
clinical preventive services not subject to cost-sharing.
Digital Breast Tomosynthesis for Breast Cancer Screening as a
Clinical Preventive Services Benefit: DHA will permanently cover
digital breast tomosynthesis (DBT), also known as 3D mammography, as a
clinical preventive services benefit not subject to cost-sharing.
Provisional Coverage Changes
Digital Breast Tomosynthesis for Breast Cancer Screening as a
Clinical Preventive Services Benefit: Provisional Coverage of DBT for
breast cancer screening, which spanned from January 1, 2020, to
December 31, 2024, will lapse. However, as noted above, DHA will
continue to cover DBT as a clinical preventive services benefit not
subject to cost-sharing.
Platelet-Rich Plasma for Major Joint Treatment and Rehabilitation:
Platelet-rich plasma (PRP) injections are excluded from coverage for
all indications. The use of PRP for knee osteoarthritis and lateral
elbow tendinopathy was covered under Provisional Coverage status from
October 1, 2019, to September 30, 2024. Provisional Coverage of PRP
lapsed on September 30, 2024, and will not be replaced with permanent
coverage.
Appendix A
Certain TRICARE enrollee out-of-pocket costs (enrollment fees,
premiums, catastrophic caps, deductibles, and copayments) are adjusted
annually by federal law and regulations based on the annual Cost of
Living Adjustment (COLA) applied to Uniformed Service member retired
pay. A difference in copayments remains between those who joined a
Uniformed Service before January 1, 2018, (Group A), and those who
joined on or after that date (Group B).
The retiree COLA is typically announced after the federal fiscal
year begins in October. Beneficiary out-of-pocket expenses impacted by
the 2025 COLA will be posted to the <a href="http://tricare.mil/changes">tricare.mil/changes</a> web page before
the start of TRICARE Open Season, November 11, 2024.
Premium Based Plans
The CY 2025 monthly premiums for TRICARE Reserve Select, TRICARE
Retired Reserve, and TRICARE Young Adult and the quarterly premiums for
Continued Health Care Benefit Program will be posted to the
<a href="http://tricare.mil/changes">tricare.mil/changes</a> web page once announced.
Pharmacy Out-of-Pocket Expenses for CY 2025
TRICARE Pharmacy copayments will remain unchanged on January 1,
2025:
Pharmacy Copayments For Calendar Year 2025 *
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Retail network
Retail network brand-name Retail network non- Mail order generic Mail order brand- Mail order Non-
Year generic formulary formulary 30-day formulary 30-day formulary 90-day name formulary 90- formulary 90-day
30-day supply supply supply supply day supply supply
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2025............................ $16 $43 $76 ** $13 $38 $76
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* Active-duty Service members (ADSM) enjoy a $0 copay for covered drugs at any pharmacy.
** For all beneficiaries except ADSM, select brand-name maintenance medications (taken for long-term conditions) may only be filled twice at retail and
then must be filled through home delivery or military pharmacy.
Dated: November 5, 2024.
Stephanie J. Bost,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2024-26066 Filed 11-7-24; 8:45 am]
BILLING CODE 6001-FR-P
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</html>Indexed from Federal Register on November 8, 2024.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.